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Background In this study, we aimed to identify and define the fundamental components of the working alliance in multidisciplinary (Flexible) Assertive Community Treatment teams with shared caseloads, in order to support their daily practice and further research. Methods After reviewing the literature, concept mapping with professionals and clients was used to define the working alliance in (F) ACT teams. The resulting concept maps formed the basis for the working alliance assessment instrument, which was pilot tested with professionals and clients through cognitive interviews with a think-aloud procedure. Results The study led to the development of a twenty five-item assessment instrument to evaluate working alliances in multidisciplinary teams (WAM) that was comprised of three subscales: bond, task/goal and team. Two different versions were developed for clients and professionals. Conclusions The WAM instrument was developed to determine the quality of the working alliance in (F) ACT teams. Future research will focus on testing its psychometric properties and predictive value.

Background:After a first episode of psychosis, cognitive impairments present an important barrier to successful (re-)entry into work and education. We assessed whether cognitive remediation (CR) as an add-on to Individual Placement and Support (IPS) can improve participation in regular employment and education.Method:Participants with early psychosis (N = 73) were randomly assigned to receive IPS supplemented with computerized CR, or IPS plus an active control intervention (computer games). The primary outcome was the number of hours spent in competitive employment or regular education, which was assessed every month during the 18-month study period. Secondary outcomes included employment rate, cognitive functioning, mental health (assessed at baseline, 6 and 18 months), and job duration (assessed after 18 months). Both patients and assessors were blind to treatment.Results:Participants receiving IPS + CR showed greater improvement of competitive employment over time in terms of hours worked (during follow-up period: 38.5 vs. 19.6 h, B = 2.94; Wald χ2 = 5.39; P = .02) and employment rate (at T2: 62.1% vs. 25.9%, χ 2 = 7.39; df = 1; P = .008), compared with the IPS + control group, particularly in the longer term. The number of hours spent in regular education was lower in the IPS + CR group, with more participants having ended education for a positive reason. There was a significant beneficial effect of adjunctive CR for executive functioning, subjective cognitive functioning, and empowerment.Conclusions:Augmenting IPS with CR has a significant impact on competitive employment in people with early psychosis, with beneficial effects being more pronounced after 18 months.

Objective: The objective of this review was to assess associations between Individual Placement and Support (IPS), employment, and personal and clinical recovery among persons with severe mental illness at 18-month follow-up.Methods: A systematic literature search identified randomized controlled trials (RCTs) comparing IPS with services as usual. Outcomes were self-esteem, empowerment, quality of life, symptoms of depression, negative or psychotic symptoms, anxiety, and level of functioning. A total of six RCTs reported data suitable for meta-analyses, and pooled original data from five studies were also analyzed.Results: Meta-analyses and analyses of pooled original data indicated that receipt of the IPS intervention alone did not improve any of the recovery outcomes. Participants who worked during the study period, whether or not they were IPS participants, experienced improved negative symptoms, compared with those who did not work (standardized mean difference [SMD]520.41, 95% confidence interval [CI]520.56, -0.26). For participants who worked, whether or not they were IPS participants, improvements were also found in level of functioning and quality of life (SMD=0.59, 95% CI=0.42, 0.77 and SMD=0.34, 95% CI=0.14, 0.54, respectively).Conclusions: Employment was associated with improvements in negative symptoms, level of functioning, and quality of life.

Accessible SummaryWhat is known on the subject?Shared decision-making is a concept originating in the medical field, and it is ideally based on a trustful relationship between the patient and the health professionals involved.Shared decision-making shows potential to strengthen patient autonomy and encourages patients to become involved in decisions regarding their treatment.What does the paper add to existing knowledge?A universal concept and understanding of shared decision-making with relevance specifically to psychiatric clinical practice could not be identified in the analysed literature.Shared decision-making refers to a process, and how and whether the patient wishes to participate in the decision-making process should be clarified from the very beginning.On the basis of this synthesizing review, a process model for psychiatric practice was specified and illustrated to help lead health professionals, patients and other supporters through the decision-making process.What are the implications for practice?The process of shared decision-making should be made visible to all persons involved, and it should be stated at the beginning that a decision must be made.Decisions regarding treatment are usually not limited to a single consultation.A collaborative approach including multiple health professionals and other supporters, such as peer workers and family members, is required.Psychiatric nurses could support patients during the process of decision-making and provide additional information, if requested.Introduction Patient involvement in decisions regarding treatment has increasingly been supported in health care, and therefore, shared decision-making (SDM), as an informative and participative approach, is promoted in the scientific literature.Aim To review the current state of research regarding the conceptual understanding and implementation of SDM in psychiatric clinical practice.Method An integrative review that included empirical, theoretical and conceptual research published between 1997 and 2019 was conducted. For this, five health-related databases were searched.Results Fourteen articles were included in the synthesis. No universal conceptual understanding of SDM regarding psychiatric care could be identified, although several articles highlighted the link with other concepts, such as autonomy and patient-centeredness. Furthermore, four additional key themes with relevance for the successful implementation of SDM in clinical practice were determined.Discussion SDM refers to a process and is usually not limited to a single consultation. SDM shows the potential to enhance patient-centred and recovery-oriented care. A collaborative approach including multiple health professionals, peer workers and family members is required.Implications for Practice The process of SDM should be made visible for all parties involved. Nurses in particular could play a key role by collecting information regarding patient's preferences and by providing support.

BackgroundIndividuals with severe mental illness experience more victimization and discrimination than other persons in the community. Effective rehabilitation and recovery-oriented care interventions aimed at addressing this issue are lacking. We therefore developed a victimization-informed intervention (accompanied by a training module for professionals) called the Victoria intervention. The purpose of the present study was to understand the trial effects by examining the implementation process and the factors that influenced it.Materials and methodsA process evaluation was conducted using a mixed-methods design. During the professionals’ intervision sessions, we used observations to understand the learning processes (n = 25). Subsequently, we studied the use of the intervention in practice through structured questionnaires (n = 215) and semi-structured interviews (n = 34) with clients and professionals. We used descriptive and inferential statistics for the quantitative data and the framework method for the analyses of the qualitative data.ResultsThe observations showed that the trainings were well received. The professionals shared the urgency of paying attention to victimization and discrimination and its harmful effects on participation. They also found the intervention steps to be logical and the intervention protocol easy to use. Nevertheless, they mentioned in the interviews that they had experienced difficulties initiating a conversation about victimization, and if they started one, they did not always follow the steps of the intervention as intended. Few clients said that victimization was placed on the agenda, though those who had discussed victimization with their caregivers expressed their appreciation in the interviews; they felt acknowledged and supported.DiscussionThe findings indicate that the intervention was considered helpful in raising awareness and the acknowledgment of victimization. However, professionals remain reluctant to talk about the subject, and the results show they need more practical training in this regard. This process evaluation has an important added value in that it helps us to understand the results of the effect evaluation of the intervention. The findings will facilitate the development and implementation of interventions that address clients’ victimization experiences in community mental healthcare settings and subsequently enable their participation in society.

Background: There are longstanding concerns regarding physical health inequalities for people with psychotic disorders. In recent years concerted efforts have been made to address these. \ud Aims: To examine whether recent national initiatives in England have led to improvements in the physical health of people with schizophrenia and related psychoses. \ud Methods: Secondary analysis of data from multiple rounds of a national audit of services for people with psychosis, conducted over a 9-year period. Proportions of patients in ‘good health’ according to seven discrete measures, and one composite measure derived from national standards, were compared between each round of the audit. \ud Results: The proportion of patients in overall ‘good health’ under the care of ‘Early Intervention in Psychosis’ (EIP) teams increased between 2014 and 2019 (OR=4.65, 95% CI 3.32 to 6.52, P

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica­tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves “recovery-oriented”, it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient’s needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

OBJECTIVE This article addresses the rise of individual placement and support (IPS) within vocational services for people with severe mental illness (SMI), the current state of affairs, and future directions of IPS in the Netherlands. METHOD Review of the literature on IPS in the Netherlands, analysis of registration data, and exploration of future avenues for IPS in Dutch mental health care. FINDINGS In the first decade of this century, an implementation study showed that IPS was feasible in the Netherlands, and a multisite randomized controlled trial (RCT) indicated that IPS was also effective in the Dutch context. Nationwide, from the start of 2016 to the end of 2017, the number of enrolled IPS participants doubled from 1,038 to 2,100, which was largely due to the introduction of preliminary national funding of IPS. Future directions include expanding the IPS practice in terms of target groups, types of providers, goals, and added interventions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Involvement of clinicians and the employment opportunities for people with SMI have increased, which is mainly due to the successes of IPS. However, considerable efforts are still needed to make IPS more widely available. Important facilitators are regular meetings of stakeholders in mental health care and vocational rehabilitation, stakeholders' experienced ownership of IPS and collaboration, the mandate and influence of the decision makers involved, and secured IPS funding. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Shared decision making is increasingly receiving attention in health care and might improve both the quality of care and patient outcomes. Nevertheless, due to its complexity, implementation of shared decision making in clinical practice seems challenging. This ethnographic study aimed to gain a better understanding of how psychiatric inpatients and the interprofessional care team interact during regular interprofessional psychiatric consultations. Data were collected through participant observation on two different psychiatric wards in a large psychiatric hospital in Switzerland. The observation focused on the contextual aspects of interprofessional patient consultations, the communication and interaction as well as the extent to which patients were involved in decision making. Participants included patients, psychiatrists, junior physicians, nurses, psychologists, social workers and therapists. We observed 71 interprofessional psychiatric consultations and they differed substantially in both wards in terms of context (place and form) and culture (way of interacting). On the contrary, results showed that the level of patient involvement in decision making was comparable and depended on individual factors, such as the health care professionals' communication style as well as the patients' personal initiative to be engaged. The main topics discussed with the patients related to pharmacotherapy and patient reported symptoms. Health care professionals in both wards used a rather unidirectional communication style. Therefore, in order to promote patient involvement in the psychiatric inpatient setting, rather than to focus on contextual factors, consultations should follow a specific agenda and promoting a bidirectional communication style for all parties involved is strongly recommended.

Shared decision making is increasingly receiving attention in health care and might improve both the quality of care and patient outcomes. Nevertheless, due to its complexity, implementation of shared decision making in clinical practice seems challenging. This ethnographic study aimed to gain a better understanding of how psychiatric inpatients and the interprofessional care team interact during regular interprofessional psychiatric consultations. Data were collected through participant observation on two different psychiatric wards in a large psychiatric hospital in Switzerland. The observation focused on the contextual aspects of interprofessional patient consultations, the communication and interaction as well as the extent to which patients were involved in decision making. Participants included patients, psychiatrists, junior physicians, nurses, psychologists, social workers and therapists. We observed 71 interprofessional psychiatric consultations and they differed substantially in both wards in terms of context (place and form) and culture (way of interacting). On the contrary, results showed that the level of patient involvement in decision making was comparable and depended on individual factors, such as the health care professionals' communication style as well as the patients' personal initiative to be engaged. The main topics discussed with the patients related to pharmacotherapy and patient reported symptoms. Health care professionals in both wards used a rather unidirectional communication style. Therefore, in order to promote patient involvement in the psychiatric inpatient setting, rather than to focus on contextual factors, consultations should follow a specific agenda and promoting a bidirectional communication style for all parties involved is strongly recommended.

BackgroundPatients with schizophrenia spectrum disorder have increased risk of coronary artery disease.AimsTo investigate long-term outcomes of patients with schizophrenia spectrum disorder and coronary artery disease after coronary artery bypass grafting surgery (CABG).MethodData from patients with schizophrenia spectrum disorder (n = 126) were retrospectively compared with propensity-matched (1:20) control patients without schizophrenia spectrum disorder (n = 2520) in a multicentre study in Finland. All patients were treated with CABG. The median follow-up was 7.1 years. The primary outcome was all-cause mortality.ResultsPatients with diagnosed schizophrenia spectrum disorder had an elevated risk of 10-year mortality after CABG, compared with control patients (42.7 v. 30.3%; hazard ratio 1.56; 95% CI 1.13–2.17; P = 0.008). Schizophrenia spectrum diagnosis was associated with a higher risk of major adverse cardiovascular events during follow-up (49.9 v. 32.6%, subdistribution hazard ratio 1.59; 95% CI 1.18–2.15; P = 0.003). Myocardial infarction (subdistribution hazard ratio 1.86; P = 0.003) and cardiovascular mortality (subdistribution hazard ratio 1.65; P = 0.017) were more frequent in patients with versus those without schizophrenia spectrum disorder, but there was no difference for stroke. Psychiatric ward admission, antipsychotic medication, antidepressant use and benzodiazepine use before CABG were not associated with outcome differences. After CABG, patients with schizophrenia spectrum disorder received statin therapy less often and had lower doses; the use of other cardiovascular medications was similar between schizophrenia spectrum and control groups.ConclusionsPatients with schizophrenia spectrum disorder have higher long-term risks of death and major adverse cardiovascular events after CABG. The results underline the vulnerability of these patients and highlight the importance of intensive secondary prevention and risk factor optimisation.

Background While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe. Methods We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style - Staff questionnaire and a set of questions regarding clinicians' expertise, training, and practice. Results SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style. Conclusions The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe., European Psychiatry Association (EPA); NIHR Nottingham Biomedical Research Centre, This research received no grant funding from any external agency, commercial or not-for-profit sector, but was financially supported by the European Psychiatry Association (EPA). M.S. acknowledges the support of the NIHR Nottingham Biomedical Research Centre.

OBJECTIVE: The objective of this review was to assess associations between Individual Placement and Support (IPS), employment, and personal and clinical recovery among persons with severe mental illness at 18-month follow-up.METHODS: A systematic literature search identified randomized controlled trials (RCTs) comparing IPS with services as usual. Outcomes were self-esteem, empowerment, quality of life, symptoms of depression, negative or psychotic symptoms, anxiety, and level of functioning. A total of six RCTs reported data suitable for meta-analyses, and pooled original data from five studies were also analyzed.RESULTS: Meta-analyses and analyses of pooled original data indicated that receipt of the IPS intervention alone did not improve any of the recovery outcomes. Participants who worked during the study period, whether or not they were IPS participants, experienced improved negative symptoms, compared with those who did not work (standardized mean difference [SMD]=-0.41, 95% confidence interval [CI]=-0.56, -0.26). For participants who worked, whether or not they were IPS participants, improvements were also found in level of functioning and quality of life (SMD=0.59, 95% CI=0.42, 0.77 and SMD=0.34, 95% CI=0.14, 0.54, respectively).CONCLUSIONS: Employment was associated with improvements in negative symptoms, level of functioning, and quality of life.

We determined the proportions of clients treated in Flexible Assertive Community Treatment teams who were unemployed and gained employment and who were employed and lost employment. Secondly, we explored the demographical and clinical factors associated with employment. Data were collected during routine outcome monitoring. We calculated differences in employment rates over a year and explored differences in demographic characteristics at baseline between patient groups. Logistic regression analysis was used to estimate the role of clinical predictor variables on employment status. Over time, 10% remained employed, 5% lost their employment, 3% gained employment and 82% remained unemployed. Clients who found employment were younger, more often male, and had significantly fewer psychosocial problems and a higher subjective quality of life during follow-up than those who remained unemployed. Problems with motivation for treatment at baseline were related to losing employment or remaining unemployed. Better implementation of vocational services is very important for increasing the number of clients gaining employment.

Background: Homelessness is an increasing problem in Western European countries. Dutch local authorities initiated cross-sectional reviews to obtain accurate health and needs information on Homeless Service (HS) users.Methods: The Homeless People Treatment and Recovery (HOP-TR) study uses a comprehensive assessment strategy to obtain health data. Using a naturalistic meta-snowball sampling in 2015–2017, 436 Dutch HS users were assessed. The lived experience of HS users was the primary data source and was enriched with professional assessments. The InterRAI Community Mental Health questionnaire and “Homelessness Supplement” provided information in different areas of life. The approach for mental health assessments was transdiagnostic. Raw interview data were recoded to assess health and needs. The positive health framework structured symptomatic, social, and personal health domains relevant to recovery.Results: Most subjects were males, low educated, with a migration background. The majority were long-term or intermittently homeless. Concurrent health problems were present in two domains or more in most (95.0%) subjects. Almost all participants showed mental health problems (98.6%); for a significant share severe (72.5%). Frequent comorbid conditions were addiction (78%), chronic physical conditions (59.2%), and intellectual impairments (39.9%).Conclusion: The HOP-TR study reveals significant concurrent health problems among Dutch HS users. The interdependent character of different needs requires an integrated 3-D public health approach to comprehensively serve symptomatic, social, and personal dimensions, required to facilitate recovery.

Background Antipsychotic-induced Weight Gain (AiWG) is a debilitating and common adverse effect of antipsychotics. AiWG negatively impacts life expectancy, quality of life, treatment adherence, likelihood of developing type-2 diabetes and readmission. Treatment of AiWG is currently challenging, and there is no consensus on the optimal management strategy. In this study, we aim to evaluate the use of metformin for the treatment of AiWG by comparing metformin with placebo in those receiving treatment as usual, which includes a lifestyle intervention. Methods In this randomized, double-blind, multicenter, placebo-controlled, pragmatic trial with a follow-up of 52 weeks, we aim to include 256 overweight participants (Body Mass Index (BMI) > 25 kg/m2) of at least 16 years of age. Patients are eligible if they have been diagnosed with schizophrenia spectrum disorder and if they have been using an antipsychotic for at least three months. Participants will be randomized with a 1:1 allocation to placebo or metformin, and will be treated for a total of 26 weeks. Metformin will be started at 500 mg b.i.d. and escalated to 1000 mg b.i.d. 2 weeks thereafter (up to a maximum of 2000 mg daily). In addition, all participants will undergo a lifestyle intervention as part of the usual treatment consisting of a combination of an exercise program and dietary consultations. The primary outcome measure is difference in body weight as a continuous trait between the two arms from treatment inception until 26 weeks of treatment, compared to baseline. Secondary outcome measures include: 1) Any element of metabolic syndrome (MetS); 2) Response, defined as ≥5% body weight loss at 26 weeks relative to treatment inception; 3) Quality of life; 4) General mental and physical health; and 5) Cost-effectiveness. Finally, we aim to assess whether genetic liability to BMI and MetS may help estimate the amount of weight reduction following initiation of metformin treatment. Discussion The pragmatic design of the current trial allows for a comparison of the efficacy and safety of metformin in combination with a lifestyle intervention in the treatment of AiWG, facilitating the development of guidelines on the interventions for this major health problem. Trial registration This trial was registered in the Netherlands Trial Register (NTR) at https://www.trialregister.nl/trial/8440 as NTR NL8840 on March 8, 2020.

Low physical activity (PA) and sedentary behavior (SB) are major contributors to mental health burden and increased somatic comorbidity and mortality in people with schizophrenia and related psychoses. Movement disorders are highly prevalent in schizophrenia populations and are related to impaired functioning and poor clinical outcome. However, the relationship between movement disorders and PA and SB has remained largely unexplored. Therefore, we aimed to examine the relationship between movement disorders (akathisia, dyskinesia, dystonia, and parkinsonism) and PA and SB in 216 patients with schizophrenia and related psychoses. Actigraphy, the St. Hans Rating Scale for extrapyramidal syndromes, and psychopathological ratings (PANSS-r) were applied. Data were analyzed using multiple linear regression, adjusting for sex, age, negative symptoms, and defined daily dose of prescribed antipsychotics. Parkinsonism was significantly associated with decreased PA (β = −0.21, P < .01) and increased SB (β = 0.26, P < .001). For dystonia, only the relationship with SB was significant (β = 0.15, P < .05). Akathisia was associated with more PA (β = 0.14, P < .05) and less SB (β = −0.15, P < .05). For dyskinesia, the relationships were non-significant. In a prediction model, akathisia, dystonia, parkinsonism and age significantly predicted PA (F(5,209) = 16.6, P < .001, R2Adjusted = 0.27) and SB (F(4,210) = 13.4, P < .001, R2Adjusted = 0.19). These findings suggest that movement disorders, in particular parkinsonism, are associated with reduced PA and increased SB in patients with psychotic disorders. Future studies should take movement disorders into account when examining PA and SB, to establish the clinical value of movement disorders in activating people with psychotic disorders to improve their mental and somatic health.

Background: People with severe mental illness have difficulties finding and maintaining competitive employment. This is particularly so for those living in supported housing who, by definition, have significant day-to-day support needs: in the Netherlands only 3 to 5% of people with serious mental health problems who live in supported housing are competitively employed. To support these people in finding and maintaining competitive employment, Individual Placement, and Support (IPS) was introduced within supported housing services in the Netherlands in 2015. As this is the first country that broadly implemented IPS in supported housing settings, this paper will focus on the first results regarding feasibility and effects on employment in clients of IPS in this sector.Methods: We investigated the feasibility and employment outcomes of delivering IPS in supported housing services using fidelity assessments and quarterly employment outcomes on IPS program level within eight supported housing organizations, and compared these with 21 mental health treatment organizations in the Netherlands over a 4 year period. We investigated possible reasons for our findings and their implications through qualitative evaluations of the IPS fidelity assessors' notes and additional focus groups with IPS specialists and coordinators from supported housing services and fidelity assessors.Results: The overall fidelity scores indicated reasonable implementation of the IPS model within both supported housing services and mental health services. However, there were differences between services with regard to specific fidelity items; mental health treatment organizations scored higher for team integration, whereas supported housing services scored higher for rapid job search and caseload size, diversity of jobs, and employers. Our qualitative data suggested that the difference in team integration between the two sectors was due to differences in their organizational and financial structures, as well as in the specific needs of their clients. Conversely, supported housing services had better connections with employers which facilitated more rapid job searching and greater diversity in employment opportunities. The average total client employment rate did not significantly differ; and was 25.8% per quarter in supported housing services and 29.6% in mental health treatment services.Conclusion: Implementing IPS in supported housing settings is both feasible and effective.

WHAT IS KNOWN ON THE SUBJECT?: Shared decision-making is a concept originating in the medical field, and it is ideally based on a trustful relationship between the patient and the health professionals involved. Shared decision-making shows potential to strengthen patient autonomy and encourages patients to become involved in decisions regarding their treatment. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: A universal concept and understanding of shared decision-making with relevance specifically to psychiatric clinical practice could not be identified in the analysed literature. Shared decision-making refers to a process, and how and whether the patient wishes to participate in the decision-making process should be clarified from the very beginning. On the basis of this synthesizing review, a process model for psychiatric practice was specified and illustrated to help lead health professionals, patients and other supporters through the decision-making process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The process of shared decision-making should be made visible to all persons involved, and it should be stated at the beginning that a decision must be made. Decisions regarding treatment are usually not limited to a single consultation. A collaborative approach including multiple health professionals and other supporters, such as peer workers and family members, is required. Psychiatric nurses could support patients during the process of decision-making and provide additional information, if requested. Abstract INTRODUCTION: Patient involvement in decisions regarding treatment has increasingly been supported in health care, and therefore, shared decision-making (SDM), as an informative and participative approach, is promoted in the scientific literature. Aim To review the current state of research regarding the conceptual understanding and implementation of SDM in psychiatric clinical practice. Method An integrative review that included empirical, theoretical and conceptual research published between 1997 and 2019 was conducted. For this, five health-related databases were searched. Results Fourteen articles were included in the synthesis. No universal conceptual understanding of SDM regarding psychiatric care could be identified, although several articles highlighted the link with other concepts, such as autonomy and patient-centeredness. Furthermore, four additional key themes with relevance for the successful implementation of SDM in clinical practice were determined. Discussion SDM refers to a process and is usually not limited to a single consultation. SDM shows the potential to enhance patient-centred and recovery-oriented care. A collaborative approach including multiple health professionals, peer workers and family members is required. Implications for practice The process of SDM should be made visible for all parties involved. Nurses in particular could play a key role by collecting information regarding patient's preferences and by providing support.

Longitudinal prospective cohorts have suggested that physical activity (PA) may be a protective factor against psychosis and schizophrenia. However, no meta-analysis has been conducted. The study aims to examine the prospective relationship between PA and incident psychosis/schizophrenia. Major databases were searched from inception to July 2019 for prospective studies that calculated the odds ratio (OR) or the adjusted odds ratio (AOR) of incident psychosis/schizophrenia in people with higher PA against people with lower PA. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects meta-analysis was conducted, for OR and AOR, separately. Across 4 cohorts (N = 30,025 median males = 50%, median follow-up = 32 years), people with high self-reported PA (versus low PA) were at reduced odds of developing psychosis/schizophrenia (OR = 0.73, 95%CI 0.532 to 0.995, p = 0.047). Analysis including 2 cohorts presenting AOR were not statistically significant (AOR = 0.59, 95%CI 0.253 to 1.383, p = 0.226). Overall study quality was high (mean NOS = 7.0). The literature on the topic is scarce, whilst crude analysis suggests that PA may be a protective factor against the emergence of psychosis/schizophrenia, but when adjusting for covariates, the association is no longer significant. Further studies with objective physical activity and adjustment for confounders are needed. ispartof: PSYCHIATRY RESEARCH vol:284 ispartof: location:Ireland status: published

OBJECTIVES: People with severe mental disorders die 10-25years earlier than people in the Western background population, mainly due to lifestyle related diseases, with cardiovascular disease (CVD) being the most frequent cause of death. Major contributors to this excess morbidity and mortality are unhealthy lifestyle factors including tobacco smoking, unhealthy eating habits and lower levels of physical activity. The aim of this study was to investigate the dietary habits and levels of physical activity in people with schizophrenia spectrum disorders and overweight and to compare the results with the current recommendations and with results from the general Danish population.METHODS: We interviewed a sample of 428 people with schizophrenia spectrum disorders and increased waist circumference enrolled in the CHANGE trial using a Food Frequency Questionnaire (FFQ) and a 24h recall interview, a Physical Activity Scale (PAS), scale for assessment of positive and negative symptoms (SAPS and SANS, respectively), Brief Assessment of Cognition in Schizophrenia (BACS) and Global Assessment of Functioning (GAF). We compared with information on dietary intake and physical activity in the general Danish population from the Danish National Survey of Dietary Habits and Physical Activity in 2011-2013 (DANSDA).RESULTS: The CHANGE participants reported a very low energy intake and their distribution of nutrients (i.e. fat, protein and carbohydrates) harmonized with the recommendations from the Danish Health Authorities, and were similar to the latest report on the dietary habits in the Danish general population. However, the intake of saturated fat, sugar and alcohol exceed the recommended amounts and the corresponding intake in the general population. The intake of fiber, vegetables and fruit and fish were insufficient and also less than in the general population. The overall estimated quality of the dietary habits was poor, only 10.7% of the participants had healthy dietary patterns, and the quality was poorer than in the general population. Even with a very liberal definition of the term "homecooked", only 62% of the participants had taken any part in the preparation of their food. The level of physical activity was low and only one fifth of the participants complied with the recommendations of min. 30min daily moderate-to-vigorous activity. Half of the CHANGE participants were smokers, compared to 17% in the general population. Negative symptoms were significantly associated with poorer dietary quality and less physical activity, whereas no such significant associations were found for cognition, positive symptoms or antipsychotic medication.CONCLUSIONS: Even when accounting for some error from recall - and social desirability bias, the findings point in the direction that the average energy intake in obese people with schizophrenia spectrum disorders is not exceeding that of the general population, and that overweight may to some degree be a result of physical inactivity and metabolic adverse effects of antipsychotic medication. The physical activity level is low and the rate of tobacco smoking is high, and our results suggest that negative symptoms play a significant role. Future research should focus on bringing about lifestyle changes in this fragile population in order to reduce the excess risk of CVD and mortality.

Background: Patients with psychotic disorders are at risk of developing mental health and social problems, and physical disorders. To monitor and treat these problems when indicated, an annual routine outcome monitoring program, Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS), was developed. This paper presents the background and content of PHAMOUS, implementation of PHAMOUS, characteristics of the patients screened in 2015, and the outcome of patients with three annual screenings between 2011 and 2015.Methods: PHAMOUS was implemented in four mental health institutions in the Northern Netherlands in 2006. During the PHAMOUS screening, patients are assessed on socio- demographics, psychiatric symptoms, medication, physical parameters, lifestyle, (psycho) social functioning and quality of life, using internationally validated instruments.Results: In 2015, 1955 patients with psychotic disorders were enrolled in the PHAMOUS screening. The majority (72%) was receiving mental healthcare for ten years or longer. A small group was hospitalized (10%) in the past year. Half of the patients were in symptomatic remission. Less than 10% had a paid job. More than half of the patients fulfilled the criteria for metabolic syndrome (54%). The subsamplewith three annual screenings from2011 to 2015 (N= 1230) was stable, except the increasing prevalence of high glucose levels and satisfaction with social relationships (Cochran's Q= 16.33, p=. 001 resp. Q= 14.79, p =.001).Conclusion: The annual PHAMOUS screening enables to follow themental, physical and social health problems of patients, which offers a good basis for shared- decision making with regard to updating the annual treatment plan, next to a wealth of data for scientific research. (C) 2018 Elsevier B. V. All rights reserved.

Purpose Psychosis has been associated with adult victimisation. However, it remains unclear whether psychosis predicts incident adult victimisation, or whether adult victimisation predicts incident psychosis. Furthermore, a moderating effect of childhood victimisation on the association between psychosis and adult victimisation has not been investigated. Methods The longitudinal association between baseline psychotic experiences and six-year incidence of adult victimisation was assessed in a prospective general population cohort of 6646 adults using logistic regression analysis. The association between baseline adult victimisation and six-year incidence of psychotic experiences was examined as well. Furthermore, the moderating effect of childhood victimisation on these bidirectional associations was analysed. Results Psychotic experiences and childhood victimisation were both associated with an increased risk of incident adult victimisation. However, this was through competing pathways, as suggested by a negative interaction between psychotic experiences and childhood victimisation. Baseline adult victimisation and childhood victimisation both independently increased the risk of incident psychotic experiences, but there was no interaction between adult victimisation and childhood victimisation. Conclusions Psychosis and victimisation are interconnected throughout the life course. Childhood victimisation is connected to psychosis through two pathways: one direct and one indirect through adult victimisation. In individuals without childhood victimisation, psychosis and adult victimisation bidirectionally impact on each other.

Background:Multimorbidity may impose an overwhelming burden on patients with psychosis and is affected by gender and age. Our aim is to study the independent role of familial liability to psychosis as a risk factor for multimorbidity.Methods:We performed the study within the framework of the Genetic Risk and Outcome of Psychosis (GROUP) project. Overall, we compared 1024 psychotic patients, 994 unaffected siblings and 566 controls on the prevalence of 125 lifetime diseases, and 19 self-reported somatic complaints. Multimorbidity was defined as the presence of two or more complaints/diseases in the same individual. Generalized linear mixed model (GLMM) were used to investigate the effects of gender, age (adolescent, young, older) and familial liability (patients, siblings, controls) and their interactions on multimorbidity.Results:Familial liability had a significant effect on multimorbidity of either complaints or diseases. Patients had a higher prevalence of multimorbidity of complaints compared to siblings (OR 2.20, 95% CI 1.79–2.69, P < 0.001) and to controls (3.05, 2.35–3.96, P < 0.001). In physical health multimorbidity, patients (OR 1.36, 95% CI 1.05–1.75, P = 0.018), but not siblings, had significantly higher prevalence than controls. Similar finding were observed for multimorbidity of lifetime diseases, including psychiatric diseases. Significant results were observed for complaints and disease multimorbidity across gender and age groups.Conclusion:Multimorbidity is a common burden, significantly more prevalent in patients and their unaffected siblings. Familial liability to psychosis showed an independent effect on multimorbidity; gender and age are also important factors determining multimorbidity.

Objective: People with psychotic disorders have an increased metabolic risk and a shortened life expectancy compared to the general population. Two large studies showed that metabolic disorders were untreated in a majority of the patients. Since then, guidelines have urged monitoring of metabolic health. This study examined the course of metabolic disorders over time in people with psychotic disorders and investigated current treatment rates. Methods: A total of 1, 259 patients with psychotic disorders, as defined by the DSM-IV, from 4 Dutch mental health institutions participated in 3 yearly assessments of the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS) between 2006 and 2014. Patients' metabolic parameters were measured, and the use of pharmacologic treatment for hypertension (systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg), dyslipidemia (5% ≤ Systematic COronary Risk Evaluation [SCORE] risk < 10% and low-density lipoprotein [LDL] cholesterol level ≥ 2.5 mmol/L or SCORE risk ≥ 10% and LDL cholesterol level ≥ 1.8 mmol/L and/or triglycerides ≥ 2.3 mmol/L), and hyperglycemia (hemoglobin A1c concentration > 7% and/or fasting glucose concentration ≥ 7.2 mmol/L) was recorded. Results: Prevalence of the metabolic syndrome, as defined by the National Cholesterol Education Program criteria, was > 50% at each assessment. On the basis of the European Society of Cardiology guidelines, pharmacotherapy for metabolic disorders was recommended for 52%-59% of the patients at each assessment. Treatment rates with antihypertensive (from 31% to 38%, P

Background The PTSD Checklist-civilian (PCL-C) is one of the most commonly used self-report measures of PTSD symptoms, however, little is known about its validity when used in pregnancy. This study aims to evaluate the reliability and validity of the PCL-C as a screen for detecting PTSD symptoms among pregnant women. Methods A total of 3372 pregnant women who attended their first prenatal care visit in Lima, Peru participated in the study. We assessed the reliability of the PCL-C items using Cronbach’s alpha. Criterion validity and performance characteristics of PCL-C were assessed against an independent, blinded Clinician-Administered PTSD Scale (CAPS) interview using measures of sensitivity, specificity and receiver operating characteristics (ROC) curves. We tested construct validity using exploratory and confirmatory factor analytic approaches. Results The reliability of the PCL-C was excellent (Cronbach’s alpha =0.90). ROC analysis showed that a cut-off score of 26 offered optimal discriminatory power, with a sensitivity of 0.86 (95% CI: 0.78–0.92) and a specificity of 0.63 (95% CI: 0.62–0.65). The area under the ROC curve was 0.75 (95% CI: 0.71–0.78). A three-factor solution was extracted using exploratory factor analysis and was further complemented with three other models using confirmatory factor analysis (CFA). In a CFA, a three-factor model based on DSM-IV symptom structure had reasonable fit statistics with comparative fit index of 0.86 and root mean square error of approximation of 0.09. Conclusion The Spanish-language version of the PCL-C may be used as a screening tool for pregnant women. The PCL-C has good reliability, criterion validity and factorial validity. The optimal cut-off score obtained by maximizing the sensitivity and specificity should be considered cautiously; women who screened positive may require further investigation to confirm PTSD diagnosis. Electronic supplementary material The online version of this article (doi:10.1186/s12888-017-1304-4) contains supplementary material, which is available to authorized users.

ObjectiveParents of children who are hospitalized in inpatient psychiatric units must cope with significant challenges. One of these challenges relates to the way in which they cope with illness-related information. The current study examined the relationship between two such coping styles – monitoring and blunting – and family burden among parents of children in a psychiatric inpatient unit. Moreover, the possible moderating roles played by hope and self-stigma in these associations were also examined.MethodsQuestionnaires regarding coping with information style, self-stigma, hope and family burden were administered to 70 parents.ResultsA main positive effect of hope and a main negative effect of self-stigma were uncovered. An interaction between self-stigma and monitoring was also revealed, suggesting that for parents with high self-stigma, compared to those with low self-stigma, more monitoring was related to more burden.ConclusionsTailoring family interventions according to coping style and self-stigma is highly recommended as a mean to reduce the family burden of parents whose child is hospitalized in a psychiatric inpatient unit.

Research suggests that childhood trauma is associated with cognitive alterations, but it is not known whether the cognitive alterations observed in patients with psychotic disorder, and their relatives, is trauma-related. Patients with a schizophrenia-spectrum diagnosis (n = 1119), siblings of patients (n = 1059) and healthy comparison subjects (HCS; n = 586) were interviewed 3 times over a period of 6 years. Repeated measures of IQ were analyzed as a function of childhood trauma and group, controlling for confounders. There were significant differences in the impact of childhood trauma on IQ across the 3 groups. Exposure in HCS was associated with a nearly 5-point reduction in IQ (-4.85; 95% confidence interval [CI]: -7.98 to -1.73, P = .002), a lesser reduction in siblings (-2.58; 95% CI: -4.69 to -0.46, P = .017) and no significant reduction in patients (-0.84; 95% CI: -2.78 to 1.10, P = .398). One-fourth of the sibling-control difference in IQ was reducible to childhood trauma, whereas for patients this was only 5%. Over the 6-year follow-up, those with trauma exposure showed significantly less learning effects with repeated cognitive assessments (b = 1.36, 95% CI: 0.80‒1.92, P < .001) than the nonexposed (b = 2.31, 95% CI: 1.92‒2.71, P < .001; P interaction = .001). Although childhood trauma impacts cognitive ability and learning in non-ill people at low and high genetic risk, its effect on the observed cognitive alterations in psychotic disorder may be minor. Twin and family studies on cognitive alterations in psychotic disorder need to take into account the differential impact of trauma on cognition across ill and non-ill, at risk groups. ispartof: Schizophrenia Bulletin vol:43 issue:2 pages:316-324 ispartof: location:United States status: published

Purpose Personality disorders (PDs) are associated with severe functional impairment and subsequent high societal costs, increasing the need to improve occupational functioning in PD. Individual placement and support (IPS) is an effective, evidence-based method of supported employment, which so far has been tested in various mixed patient populations with severe mental illness (SMI, including PDs). However, the effectiveness of IPS for PDs per se remains uninvestigated. Methods Data from the SCION trial were used, including 31 SMI patients with PDs and 115 SMI patients with other primary diagnoses (primarily psychotic disorders). First, the interaction effect of diagnosis (PD vs other SMI) and intervention (IPS vs traditional vocational rehabilitation) was studied. Second, in the IPS condition, difference between diagnostic groups in time to first job was studied. Results We did not find evidence of a moderating effect of PD diagnosis on the primary effect of IPS (proportion who started in regular employment) (OR = 0.592, 95% CI 0.80–4.350, p = 0.606) after 30 months. Also, PD diagnosis did not moderate the effect of time until first job in IPS. Conclusions From the present explorative analysis we did not find evidence for a moderating effect of PD diagnosis on the effectiveness of IPS among PD participants. This indicates that IPS could be as effective in gaining employment in participants with PD as it is in participants with other SMI. Future studies, implementing larger numbers, should confirm whether IPS is equally effective in PDs and study whether augmentations or alterations to the standard IPS model might be beneficiary for PD.

The purpose of this study was to examine the dietary intake of both inpatients and outpatients with schizophrenia in the Portuguese population as a potential key contributing factor to the poor physical health profiles, and understand the relationship of diet quality to other lifestyle factors. Participants of this cross-sectional study completed a semi quantitative food frequency questionnaire. Diet quality was determined by adherence to the Mediterranean Diet. In addition participants completed the International Physical Activity Questionnaire-Short-Form and Pittsburgh Sleep Quality Index. Tobacco smoking was assessed through a series of general questions. A total of 100 patients (50% inpatients and 28% female) with schizophrenia were included in the final analysis. Patients reported a high consumption of caffeine, while deficits were evident for fibre and folate intakes, when compared to the European Food Safety Authority recommendations. Both inpatients and outpatients reported poor to moderate diet quality. Smokers reported poorer diet quality when compared to non-smokers (p

Background: Case management is a client-centered approach to improve the coordination and continuity of service delivery, especially for persons with substance use disorders (SUD) and multiple and complex support needs. This intervention supports individuals by helping them identify needed services, facilitate linkage with services, and promote participation and retention in services. However, it is questionable whether case management is equally effective in promoting recovery and aspects of personal functioning. The objective was to conduct an updated meta-analysis and to assess whether case management was more effective than treatment as usual (TAU) among persons with SUD for improving treatment-related (e.g., successful linkage with and retention in treatment) as well as personal functioning outcomes (e.g., substance use). Methods: This meta-analysis focuses on randomized controlled trials (RCTs) that included persons with alcohol or drug use disorders and compared case management with TAU. To be eligible, interventions had to meet core case management functions as defined in the literature. We conducted searches of the following databases to May 2017: the Cochrane Drugs and Alcohol Specialized Register, CENTRAL, PubMed, Embase, CINAHL, and Web of Science. Also, reference lists of retrieved publications were scanned for relevant (un)published studies. Results: The overall effect size for case management compared to TAU across all outcome categories and moments was small and positive (SMD = 0.18, 95% CI 0.07-0.28), but statistically significant. Effects were considerably larger for treatment tasks (SMD = 0.33, 95% CI 0.18-0.48) than for personal functioning outcomes (SMD = 0.06, 95% CI -0.02 to 0.15). The largest effect sizes were found for retention in substance abuse treatment and linkage with substance abuse services. Moderator effects of case management models and conditions were assessed, but no significant differences were observed. Conclusions: The primary results from earlier meta-analyses were supported: case management is more effective than TAU conditions for improving outcomes, but this effect is significantly larger for treatment-related tasks than for personal functioning outcomes. Case management can be an important supplement to available services for improving linkage and retention, although further research is needed to assess its potential for supporting recovery from a longitudinal perspective. ispartof: FRONTIERS IN PSYCHIATRY vol:10 issue:MAR ispartof: location:Switzerland status: published

INTRODUCTION: Although people with a psychotic disorder are approximately four to six times more often victimized than the general population, victimization is not routinely assessed in mental healthcare. This study investigates prevalence, context and risk factors of victimization in patients with a psychotic disorder in the Northern, relatively rural region of the Netherlands. Moreover, disclosure rates and awareness of psychiatrists are examined.METHOD: Information on personal crime (threats, assaults and sexual violence), property and other forms of crime, the context of victimization and disclosure was routinely assessed in 353 patients with a psychotic disorder who received care at a mental health facility. In addition, involved psychiatrists reported on last year's victimization incidents in their patients.RESULTS: One third of the patients reported victimization in the previous year. More than half of the crimes were committed by someone acquainted and took place in the victim's own home or a place familiar to the victim. Younger age, having a comorbid disorder, drug use and perpetration of a crime were all positively associated with victimization. Approximately half of the reported personal crimes were disclosed to a health care professional but only in 16% of the cases the involved psychiatrist report to know about the incident.CONCLUSION: This study confirms that people with a history of psychosis have an increased risk of becoming the victim of a crime. Although our results suggest that in fifty percent of cases the patients did share the information with professionals, a substantial proportion of incidents appear to go still unnoticed.

This study examined the perceived costs, benefits, and motivations for participating in individual trauma-focused interviews among forensic psychiatric patients ( N = 74). The majority of our participants were male, and 100% endorsed adverse childhood experiences (e.g., abuse, neglect) or exposure to potentially traumatic events (e.g., assault). Levels of posttraumatic avoidance (41.9%), reexperiencing (59.5%), and increased arousal (51.3%) were high. In line with previous studies, our findings suggest an overall positive research experience in this sample. In spite of extensive histories of lifetime victimization we did not find an association between victimization, posttraumatic symptomatology, and a negative research experience. Our findings suggest that participation in trauma-focused research is not only possible with, but also potentially beneficial for forensic patients.

Importance: Key outcomes for persons with psychiatric disorders include subjection to violence and perpetration of violence. The occurrence of these outcomes and their associations with psychiatric disorders need to be clarified. Objective: To estimate the associations of a wide range of psychiatric disorders with the risks of subjection to violence and perpetration of violence. Design, Setting, and Participants: A total of 250 419 individuals born between January 1, 1973, and December 31, 1993, were identified to have psychiatric disorders using Swedish nationwide registers. Premorbid subjection to violence was measured since birth. The patients were matched by age and sex to individuals in the general population (n = 2 504 190) and to their full biological siblings without psychiatric disorders (n = 194 788). The start date for the patients and control groups was defined as the discharge date of the first psychiatric episode. The participants were censored either when they migrated, died, experienced the outcome of interest, or reached the end of the study period on December 31, 2013. Data were analyzed from January 15 to September 14, 2019. Exposures: Patients with common psychiatric disorders (eg, schizophrenia, bipolar disorder, depression, and anxiety) were differentiated using a hierarchical approach. Patients with personality disorders and substance use disorders were also included. Main Outcomes and Measures: Subjection to violence was defined as an outpatient visit (excluding a primary care visit), inpatient episode, or death associated with any diagnosis of an injury that was purposefully inflicted by other persons. Perpetration of violence was defined as a violent crime conviction. Stratified Cox regression models were fitted to account for the time at risk, a range of sociodemographic factors, a history of violence, and unmeasured familial confounders (via sibling comparisons). Results: Among 250 419 patients (55.4% women), the median (interquartile range) age at first diagnosis ranged from 20.0 (17.4-24.0) years for alcohol use disorder to 23.7 (19.9-28.8) years for anxiety disorder. Compared with 2 504 190 matched individuals without psychiatric disorders from the general population, patients with psychiatric disorders were more likely to be subjected to violence (7.1 [95% CI, 6.9-7.2] vs 1.0 [95% CI, 0.9-1.0] per 1000 person-years) and to perpetrate violence (7.5 [95% CI, 7.4-7.6] vs 0.7 [95% CI, 0.7-0.7] per 1000 person-years). In the fully adjusted models, patients with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to be either subjected to violence (adjusted hazard ratio [aHR], 3.4 [95% CI, 3.2-3.6]) or to perpetrate violence (aHR, 4.2 [95% CI, 3.9-4.4]). Diagnosis with any of the specific disorders was associated with higher rates of violent outcomes, with the sole exception of schizophrenia, which was not associated with the risk of subjection to violence. Conclusions and Relevance: In this study, persons with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to have been subjected to violence or to have perpetrated violence after the onset of their conditions. The risks of both outcomes varied by specific psychiatric diagnosis, history of violence, and familial risks. Clinical interventions may benefit from targeted approaches for the assessment and management of risk of violence in people with psychiatric disorders.

Background Depression is a prevalent and disabling mental disorder that frequently co-occurs with a wide range of chronic conditions. Evidence has suggested that depression could be associated with excess all-cause mortality across different settings and populations, although the causality of these associations remains unclear. Methods We conducted an umbrella review of systematic reviews and meta-analyses of observational studies. PubMed, PsycINFO, and Embase electronic databases were searched through January 20, 2018. Systematic reviews and meta-analyses that investigated associations of depression and all-cause and cause-specific mortality were selected for the review. The evidence was graded as convincing, highly suggestive, suggestive, or weak based on quantitative criteria that included an assessment of heterogeneity, 95% prediction intervals, small-study effects, and excess significance bias. Results A total of 26 references providing 2 systematic reviews and data for 17 meta-analytic estimates met inclusion criteria (19 of them on all-cause mortality); data from 246 unique studies (N = 3,825,380) were synthesized. All 17 associations had P

BACKGROUND: Psychiatric patients are at high risk of becoming victim of a violent crime compared to the general population. Although most research has focused on patients with severe mental illness, depressed patients have been demonstrated to be prone to victimization as well. Victimization is associated with more severe symptomatology, decreased quality of life, and high risk of revictimization. Hence, there is a strong need for interventions that focus on preventing violent revictimization. Since emotion dysregulation is associated with both victimization and depression, we developed an internet-based Emotion Regulation Training (iERT) to reduce revictimization in depressed patients. This study aims to evaluate the clinical and cost-effectiveness of iERT added to Treatment As Usual (TAU) in reducing incidents of violent revictimization among depressed patients with a recent history of victimization. Furthermore, this study aims to examine secondary clinical outcomes, and moderators and mediators that may be associated with treatment outcomes.METHODS: In a multicenter randomized controlled trial with parallel group design, patients with a major depressive disorder and a history of violent victimization over the past three years (N = 200) will be allocated to either TAU + iERT (N = 100) or TAU only (N = 100), based on computer-generated stratified block randomization. Assessments will take place at baseline, 8 weeks, 14 weeks, and 6 months after start of treatment, and 12, 24, and 36 months after baseline. The primary outcome measure is the total number of violent victimization incidents at 12 months after baseline, measured with the Safety Monitor: an adequate self-report questionnaire that assesses victimization over the preceding 12 months. Secondary outcome measures and mediators include emotion dysregulation and depressive symptomatology. An economic evaluation with the societal perspective will be performed alongside the trial.DISCUSSION: This study is the first to examine the effectiveness of an intervention aimed at reducing violent revictimization in depressed patients. If effective, iERT can be implemented in mental health care, and contribute to the well-being of depressed patients. Furthermore, the results will provide insight into underlying mechanisms of revictimization.TRIAL REGISTRATION: The study is registered at the Netherlands Trial Register ( NTR5822 ). Date of registration: 4 April 2016.

AIM: To investigate predictors of falls/fractures leading to hospitalisation in people with schizophrenia-spectrum disorders. METHODS: A historical cohort of people with schizophrenia-spectrum disorders (ICD F20-29) from 01/2006-12/2012 was assembled using data from the South London and Maudsley NHS Biomedical Research Centre Case Register. Falls/fractures were ascertained from a linkage to national hospitalisation data. Separate multivariate Cox regression analyses were employed to identify predictors of falls and fractures. RESULTS: Of 11,567 people with schizophrenia-spectrum disorders (mean age 42.6 years, 43% female), 579 (incidence rate 12.79 per 1000 person-years) and 528 (11.65 per 1000 person-years) had at least one reported hospital admission due to a fall or fracture respectively and 822 patients had at least either a recorded fall or a fracture during this period (i.e. 7.1% of sample). Overall, 6.69 and 10.74 years of inpatient hospital stay per 1000-person years of follow-up occurred due to a fall and fracture respectively. 14(0.12%) and 28(0.24%) died due to a fall and fracture respectively. In Multivariable analysis, increasing age, white ethnicity, analgesics, cardiovascular disease, hypertension, diseases of the genitourinary system, visual disturbance and syncope were significant risk factor for both falls and fractures. A previous fracture (HR 2.05, 95% CI 1.53-2.73) and osteoporosis (HR 6.79, 95% CI 4.71-9.78) were strong risk factors for consequent fractures. CONCLUSION: Comorbid physical health conditions and analgesic medication prescription were associated with higher risk of falls and fractures. Osteoporosis and previous fracture were strong predictors for subsequent fractures. Interventions targeting bone health and falls/fractures need to be developed and evaluated in these populations. ispartof: SCHIZOPHRENIA RESEARCH vol:201 pages:70-78 ispartof: location:Netherlands status: published